As countries undergo their health financing transitions, moving away from external and out-of-pocket (OOP) financing toward domestically sourced public financing, the issue of fiscal space – that is, of finding ways to increase public financing in an efficient, equitable, and sustainable manner -- is front and center in the policy dialogue around universal health coverage (UHC).
... See More + Although how money is expended is just as critical as the overall resource envelope, we analyze changes in per capita public financing for health in real terms, a proxy for realized fiscal space, within and across 151 countries over time. This allows for an assessment not just of trends in public financing for health but also of contributions from three macro-fiscal drivers -- economic growth, changes in aggregate public spending, and reprioritization for health -- exploiting a macroeconomic identity that captures the relationship between these factors. Analysis of data from 2000 to 2015 shows per capita public financing for health in low- and middle-income countries increased by 5.0 percent per year on average: up from US$60 (2.2 percent of GDP) in 2000 to US$117 (2.8 percent of gross domestic product [GDP]) in 2015. Some of the largest increases were in countries in the Europe and Central Asia (ECA) and East Asia and Pacific (EAP) regions. At 3.1 percent per year, annual growth in public financing for health was lower among high-income countries, albeit from a much higher baseline in 2000. Increases in on-budget external financing comprised most of the changes among low-income countries, whereas domestic government revenues dominated changes in composition of public financing among lower- and upper-middle-income countries. Public financing increased at a faster rate than OOP sources for health in most regions except for South Asia. Although there are important country-specific differences, it is notable that more than half of the increase in public financing for health was due to economic growth alone. For the remainder of the increase, aggregate public spending contributed more than reprioritization across low and lower-middle-income countries, whereas the reverse was true in high-income countries. One key point of note from the landscaping exercise summarized in the paper is the diversity of growth trajectories across countries and, especially, the volatility in trends over time. The implications are clear: capturing public financing with a single growth rate is not the best metric to characterize country experiences, many of which are punctuated by episodes wherein trends are flat or have varying degrees of growth rates (positive or negative). Although country context matters, the importance of economic growth for public financing for health underscores the critical need to situate, integrate, leverage, and proactively manage health financing reforms within a country’s overall macro-fiscal context and to assess different pillars of fiscal space holistically.
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This paper draws lessons from anti-fraud experiences in social health insurance programs of six selected countries across the income spectrum: Indonesia, the Philippines, Republic of Korea, Croatia, Turkey, and the United States.
... See More + A standardized questionnaire was used to collect information on how the programs prevent, detect, and deter fraud. The questionnaire was supplemented by a literature review and conversations with key informants. The analysis summarizes similarities and differences in the legal framework, institutional mechanisms, and capacity to manage fraud. Across all countries, the primary responsibility for managing fraud lies with the public entity that administers the program. In terms of capacity, all program-administering agencies have dedicated anti-fraud units and staff. In addition, all countries have specific anti-fraud policies and guidelines that address fraud and have a clear operational and legal definition of fraud. In terms of preventing fraud, the use of pre-authorization screening for high-end procedures is common. For detecting fraud, most countries use anti-fraud ‘hotlines’ and encourage other forms of reporting of suspected fraudulent behavior; the use of ‘red flags’-triggers that identify suspicious claims based on deviations from norms, is also common. The level of sophistication in using data analytics to detect potential fraud, however, varies across countries. Social health insurance programs in higher-income countries are more likely to use advanced statistical and data-mining techniques compared to those in lower-income countries. All programs across all countries undertake post-reimbursement medical claims and beneficiary audits. In terms of deterring fraud, sanctions often include the use of financial penalties, cancellation of contracts, and criminal prosecutions; however, in most countries, public providers are not penalized and prosecuted to the same degree as private providers.
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Globally more than 7 million deaths a year are attributed to tobacco use, approximately 10 percent of which are among nonsmokers exposed to secondhand smoke.
... See More + Most of these deaths occur in low- and middle-income countries (LMICs), and among a relatively young population. If current smoking patterns continue, tobacco will kill about one billion people this century. Tobacco taxes are among the most cost-effective tobacco control measures in the world. Yet often countries are reluctant to raise tobacco taxes due to their perceived regressivity. This study simulates the impact of higher tobacco prices resulting from increases in tobacco excise tax in the Kyrgyz Republic. The study uses extended cost-effectiveness analysis to measure the distributional consequences of proposed excise tax increases on: (a) averted premature tobacco-related deaths; (b) averted out-of-pocket (OOP) expenditures on treating tobacco-related disease; (c) government savings resulting from averted treatment costs for those covered under the State Guaranteed Benefit Package; and (d) averted poverty cases as a result of OOP spending. The Kyrgyz Republic has already introduced gradual tobacco tax increases that will take place up to 2022, but steps should be taken to ensure that these increases result in real price increases and to strengthen other tobacco control measures such as ensuring access to cessation services.
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The majority of Armenian adult males smoke, yet tobacco taxes in Armenia are among the lowest in Europe and Central Asia. Increasing taxes on tobacco is one of the most cost-effective public health interventions, but many opponents often cite regressively as an argument against tobacco taxation.
... See More + The author uses a mixed-methods approach to study the potential regressively of tobacco taxation and the extent to which the regressively argument hindered increases in tobacco taxation in Armenia. First, we pursued an extended cost-effectiveness analysis (ECEA) to assess the health, financial, and distributional consequences (by consumption quintile) of increases in the excise tax on cigarettes in Armenia. We simulated a hypothetical price hike leading to a tax rate of about 75 percent of the retail price of cigarettes, which would be fully passed on to consumers. Second, we conducted a series of stakeholder interviews to examine the importance of the regressively argument and identify the factors that allowed tobacco tax increases to be adopted as public policy in Armenia. The author show that increased excise taxes would bring large health and financial benefits to Armenian households. Half of tobacco-related premature deaths and 27 percent of associated poverty cases averted would be concentrated among the bottom 40 percent of the population. Though regressively was raised as a concern at the initial stages of the policy adoption process, our qualitative stakeholder analysis indicates that the recent accession to the Eurasian Economic Union and the fiscal constraints faced by the government created a window of opportunity for tobacco taxation to be placed on the policy agenda and adopted as government policy, and the ECEA findings were an important input into the process.
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At present, tobacco taxes in Armenia are among the lowest in Europe and Central Asia. Global experience has shown that increasing taxes on tobacco is one of the most cost effective public health interventions.
... See More + This is particularly relevant for Armenia, where smoking is among the leading risk factors of mortality among the population. Methods: We conducted an extended cost-effectiveness analysis (ECEA) to assess the health, financial, and distributional consequences of increases in the excise tax on cigarettes in Armenia.
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There is a policy measure that can simultaneously save millions of lives, reduce poverty, and increase countries’ domestic resources for financing development.
... See More + The policy measure consists of increasing excise tax rates on tobacco in order to reduce its affordability and, as evidence shows, lower its consumption. Today, this powerful human development and poverty reduction measure remains largely underutilized, especially in low- and middle-income countries (LMICs). This report provides decision support for policy makers on tobacco tax reform, as well as analytical and empirical tools for using tobacco excise taxes to save lives and increase government revenues. The report sets forth the public health, economic, and anti-poverty case for higher tobacco taxes; shows how some countries have already delivered ambitious reforms; and documents measurable results. It shows that, by implementing tobacco tax reforms now, policy makers can choose a fast road to healthier, more prosperous societies.
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There is a policy measure that can simultaneously save millions of lives, reduce poverty, and increase countries’ domestic resources for financing development.
... See More + The policy measure consists of increasing excise tax rates on tobacco in order to reduce its affordability and, as evidence shows, lower its consumption. Today, this powerful human development and poverty reduction measure remains largely underutilized, especially in low- and middle-income countries (LMICs). This report provides decision support for policy makers on tobacco tax reform, as well as analytical and empirical tools for using tobacco excise taxes to save lives and increase government revenues. The report sets forth the public health, economic, and anti-poverty case for higher tobacco taxes; shows how some countries have already delivered ambitious reforms; and documents measurable results. It shows that, by implementing tobacco tax reforms now, policy makers can choose a fast road to healthier, more prosperous societies.
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There is a policy measure that can simultaneously save millions of lives, reduce poverty, and increase countries’ domestic resources for financing development.
... See More + The policy measure consists of increasing excise tax rates on tobacco in order to reduce its affordability and, as evidence shows, lower its consumption. Today, this powerful human development and poverty reduction measure remains largely underutilized, especially in low- and middle-income countries (LMICs). This report provides decision support for policy makers on tobacco tax reform, as well as analytical and empirical tools for using tobacco excise taxes to save lives and increase government revenues. The report sets forth the public health, economic, and anti-poverty case for higher tobacco taxes; shows how some countries have already delivered ambitious reforms; and documents measurable results. It shows that, by implementing tobacco tax reforms now, policy makers can choose a fast road to healthier, more prosperous societies.
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There is a policy measure that can simultaneously save millions of lives, reduce poverty, and increase countries’ domestic resources for financing development.
... See More + The policy measure consists of increasing excise tax rates on tobacco in order to reduce its affordability and, as evidence shows, lower its consumption. Today, this powerful human development and poverty reduction measure remains largely underutilized, especially in low- and middle-income countries (LMICs). This report provides decision support for policy makers on tobacco tax reform, as well as analytical and empirical tools for using tobacco excise taxes to save lives and increase government revenues. The report sets forth the public health, economic, and anti-poverty case for higher tobacco taxes; shows how some countries have already delivered ambitious reforms; and documents measurable results. It shows that, by implementing tobacco tax reforms now, policy makers can choose a fast road to healthier, more prosperous societies.
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There is a policy measure that can simultaneously save millions of lives, reduce poverty, and increase countries’ domestic resources for financing development.
... See More + The policy measure consists of increasing excise tax rates on tobacco in order to reduce its affordability and, as evidence shows, lower its consumption. Today, this powerful human development and poverty reduction measure remains largely underutilized, especially in low- and middle-income countries (LMICs). This report provides decision support for policy makers on tobacco tax reform, as well as analytical and empirical tools for using tobacco excise taxes to save lives and increase government revenues. The report sets forth the public health, economic, and anti-poverty case for higher tobacco taxes; shows how some countries have already delivered ambitious reforms; and documents measurable results. It shows that, by implementing tobacco tax reforms now, policy makers can choose a fast road to healthier, more prosperous societies.
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There is a policy measure that can simultaneously save millions of lives, reduce poverty, and increase countries’ domestic resources for financing development.
... See More + The policy measure consists of increasing excise tax rates on tobacco in order to reduce its affordability and, as evidence shows, lower its consumption. Today, this powerful human development and poverty reduction measure remains largely underutilized, especially in low- and middle-income countries (LMICs). This report provides decision support for policy makers on tobacco tax reform, as well as analytical and empirical tools for using tobacco excise taxes to save lives and increase government revenues. The report sets forth the public health, economic, and anti-poverty case for higher tobacco taxes; shows how some countries have already delivered ambitious reforms; and documents measurable results. It shows that, by implementing tobacco tax reforms now, policy makers can choose a fast road to healthier, more prosperous societies.
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Relative to other comparable income and health spending countries, Bulgaria has more physicians per capita. Bulgaria’s physician to population ratio increased from 2.5 in 1980 to 3.8 physicians per 1000 population in 2011.
... See More + The physician to population ratio is comparable to the EU-12 average of 3.8 physicians per 1000 population in 2012 but is higher than the EU-15 average of 3.1 physicians per 1000 population in 2012. Bulgaria has achieved significant improvements in health outcomes over time but is still falling behind most EU countries on key health indicators. Infant mortality decreased from 24.5 in 1980 to 10.5 per 1,000 live births in 2012 (Figure 5). Infant mortality in Bulgaria is slightly lower relative to other comparable income and health spending countries. Despite the significant reduction, however, Bulgaria’s infant mortality rate is still more than three times higher than the EU-15 average of 3.2 infant deaths per 1000 live births and almost twice as high as the EU-12 average of 5.5 infant deaths per 1000 live births. More significant improvements were achieved in reducing maternal mortality, which fell from 24 deaths per 100,000 live births in 1990 to 8 deaths per 100,000 live births in 2010. The maternal mortality ratio in Bulgaria is low compared to the global averages relative to income and health spending. Bulgaria has surpassed the EU-12 average of 11.3 deaths per 100,000 live births and is approaching the EU-15 average of 7.6 deaths per 100,000 live births.
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Health financing in Bulgaria is organized in a way that should, in theory, allow the system to deliver good performance. In particular, the national health insurance fund was set up to provide universal coverage, and the provider-payment system contains elements of international best practices.
... See More + The hospital-centric service delivery structure is not well targeted to the predominant and growing burden of non-communicable diseases, and loopholes in the provider-payment system reinforce this bias toward expensive hospital care. The first part of this report presents a health financing diagnostic to assist the Government of Bulgaria in developing health financing reform options that improve the efficiency, equity, and long-term sustainability of the Bulgarian health system. The second part reviews the reform agenda currently envisaged by the government with a focus on health financing aspects. It presents practical suggestions, drawn from international experience, which should support the government as it moves toward implementing its reform agenda. These suggestions aim to enhance the reforms’ capacity to address some of the performance gaps highlighted in part one with respect to efficiency, sustainability, and capacity to provide financial protection.
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This case study unravels Turkey's path to universal coverage. It outlines both the transformation of the health system and the performance of the 'Yesil Kart', the Green Card, program, a noncontributory health insurance scheme for the poor.
... See More + Initially launched in 1992, the Green Card program has seen a rapid expansion in the number of beneficiaries and program benefits since the implementation of the Health Transformation Program, or HTP in 2003, with the number of beneficiaries more than tripling, from 2.5 million beneficiaries in 2003 to 9.1 million beneficiaries in 2011. In addition, both the coverage and targeting of the program improved substantially. While the Green Card program initially began as a separate targeted scheme for the poor, in January 2012 it became part of the UHI scheme managed by Social Security Institution, or SSI. As this study will show, gradual steps were taken over the years to expand coverage, improve targeting, and expand benefits of the Green Card program to align it with the UHI. This, combined with the improvements in service delivery within a comprehensive reform of the health sector, makes Turkey a unique example of universal coverage for quality health services. The study is organized as follows. Section two briefly outlines Turkey's health reform and how health care is currently organized and delivered. Section three describes the Green Card Program, it evolution, and its performance. The final section discusses the pending agenda.
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